Wholesale Customer Application
Business Name
*
DBA Name if different
Ship-to Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Billing-to Address (if different from ship-to)
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.
Format: (000) 000-0000.
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Business Structure
*
Please Select
Sole Proprietor
Partnership
Limited Liability Company
Corporation
Other
Business Type
*
Please Select
College/University/Government Entity
Restaurant
Retailer
Bakery
Food processor/manufacturer
Distributor
Farmer
Other
Business Description (tell us about your business)
Number of years in business
*
Number of years in current location
*
Tax ID
*
State Business Registration Number
*
State Business is Registered In
*
Upload your state reseller's permit if applicable
Browse Files
Drag and drop files here
Choose a file
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Authorized Buyers
Authorized Buyer
*
First Name
Last Name
Authorized Buyer Email
*
example@example.com
Authorized Buyer Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Additional Authorized Buyer
First Name
Last Name
Additional Authorized Buyer Email
example@example.com
Additional Authorized Buyer Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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Principals/Owners
Please note that physical addresses are required; PO Boxes are not accepted
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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Accounts Payable Information
AP Contact
*
First Name
Last Name
AP Email
*
example@example.com
AP Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Payment Method
*
Please Select
COD
Credit Card
Bank Name
*
Bank Contact
*
First Name
Last Name
Bank Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Bank Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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Are you interested in applying for credit terms?
Please Select
Yes
No
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Credit Limit Requested
Three Trade References
Please provide 3 trade references of businesses that have extended Terms to you. No credit card accounts, services, utilities, landlords, insurance, etc. Incomplete information on this form may delay credit approval. Terms will only be offered once eligibility is confirmed.
Vendor Name #1
Terms with Vendor #1
Vendor #1 Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Vendor #1 Contact Name
First Name
Last Name
Vendor #1 Contact Title
Vendor #1 Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Vendor Name #2
Terms with Vendor #2
Vendor #2 Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Vendor #2 Contact Name
First Name
Last Name
Vendor #2 Contact Title
Vendor #2 Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Vendor Name #3
Terms with Vendor #3
Vendor #3 Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Vendor #3 Contact Name
First Name
Last Name
Vendor #3 Contact Title
Vendor #3 Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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Delivery Questionnaire
Is the delivery address residential or business?
Residential
Business
Is the delivery address yours or a third party's?
Ours
Third Party
Is the business name visible from the road or is there a landmark near the delivery location?
Receiving Hours
Receiver Name
Receiver Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Can the delivery address be access by a 40' long x 13.5' high truck?
Yes
No
Can the delivery address accommodate a pallet drop delivery?
Yes
No
Does the delivery address have a forklift?
Yes
No
Does the delivery address have a loading dock?
Yes
No
Anticipated frequency of orders?
Roughly what volume will you be ordering?
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Signature
Please verify that you are human
*
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